Ethical considerations when preadolescents request elective or cosmetic dermatologic interventions
Authors: Kaylin Beiter, Kimberly Sable, Lisa Arkin
Journal: Journal of the American Academy of Dermatology (2023)

Dear Dr Dermatoethicist: An 8-year-old female recently presented to our clinic requesting elective removal of a small (<1 cm) benign melanocytic facial nevus. She denied being bullied but did report limiting academic and social engagement because of the lesion. Given that preadolescent patients are not old enough to assent to elective treatments, how should I proceed?—Pediatric Dermatologist Dear Dr Dermatoethicist: An 8-year-old female recently presented to our clinic requesting elective removal of a small (<1 cm) benign melanocytic facial nevus. She denied being bullied but did report limiting academic and social engagement because of the lesion. Given that preadolescent patients are not old enough to assent to elective treatments, how should I proceed? —Pediatric Dermatologist Dear Pediatric Dermatologist: Elective and cosmetic interventions remain ethically controversial in medicine overall.1Nejadsarvari N. Ebrahimi A. Ebrahimi A. Hashem-Zade H. Medical ethics in plastic surgery: a mini review.World J Plast Surg. 2016; 5: 207-212PubMed Google Scholar,2Bermant M.A. Ethics of cosmetic plastic surgery in adolescents.Virtual Mentor. 2005; 7: 257-261https://doi.org/10.1001/virtualmentor.2005.7.3.oped2-0503Crossref Scopus (1) Google Scholar In particular, there has been limited discussion of the ethics of elective and cosmetic interventions for preadolescents, a group with limited medical decision-making capacity.3Grootens-Wiegers P. Hein I.M. van den Broek J.M. de Vries M.C. Medical decision-making in children and adolescents: developmental and neuroscientific aspects.BMC Pediatr. 2017; 17: 120https://doi.org/10.1186/s12887-017-0869-xCrossref PubMed Scopus (140) Google Scholar Bodily dissatisfaction is surprisingly common in preadolescent children, affecting up to 75% of children aged 9 to 12.4Mendo-Lazaro S. Polo-del-Rio M. Amado-Alonso D. Inglesias-Gallego D. Leon-del-Barco B. Self-concept in childhood: the role of body image and sport practice.Front Psychol. 2017; 8: 853https://doi.org/10.3389/fpsyg.2017.00853Crossref PubMed Scopus (26) Google Scholar Body dysmorphic disorder (BDD), a severe, pathologic form of body dissatisfaction, affects less than 2% of the population. However, these patients may be more likely to present to dermatologists and may comprise up 10% to 20% of all general dermatology patients.5Dennin M.H. Lee M.S. Body dysmorphic disorder in pediatric dermatology.Pediatr Dermatol. 2018; 35: 868-874https://doi.org/10.1111/pde.13581Crossref PubMed Scopus (5) Google Scholar Of note, dissatisfaction over specific lesions does not equate with overt psychological distress. Preadolescent patients are not able to provide fully informed assent and clinicians should firmly empower parents to retain final decision making. Dermatologists should engage with parents in shared decision making while including the child to mitigate the risk of creating a parent versus child dynamic. Dermatologists must also carefully approach these discussions and prevent stigmatization or suggestion of overt pathology. Furthermore, dermatologists must be direct about procedure costs, given that cosmetic lesion removal is not billable to the patient's insurance. In the absence of red flags for BDD, and after discussion, the dermatologist may consider nevus removal. Visual demonstration of the risks of nevus removal could aid in the patient's ability to conceptualize the risks and benefits of subsequent facial nevus removal. Potential demonstrative tools could include temporary adhesive strips (eg, scars/discoloration drawn onto the adhesive). This may be particularly relevant for patients with a known familial propensity towards hypertrophic scars/keloid formation. In general, the clinician should inquire about the reason for and degree of fixation on the lesion, most bothersome feature of the lesion, and associated functional deficits and distress.5Dennin M.H. Lee M.S. Body dysmorphic disorder in pediatric dermatology.Pediatr Dermatol. 2018; 35: 868-874https://doi.org/10.1111/pde.13581Crossref PubMed Scopus (5) Google Scholar Though there is not yet a validated, clinically relevant tool for BDD screening in preadolescents, the Body Image Questionnaire may be the most adaptable for this population.5Dennin M.H. Lee M.S. Body dysmorphic disorder in pediatric dermatology.Pediatr Dermatol. 2018; 35: 868-874https://doi.org/10.1111/pde.13581Crossref PubMed Scopus (5) Google Scholar If the child's concerns persist or worsen over time with associated social-cognitive detriment (eg, bullying, poor self-image/confidence) and the parent consents, the lesion should be removed. Pediatric patients requesting elective and cosmetic procedures constitute a special clinical scenario in dermatologic practice. For patients who are not of sufficient developmental age to fully grasp risks, benefits, and alternatives to treatments, it is imperative to first assess for underlying BDD. The dermatologist should continue to support and reinforce the patient's parent as the primary authority and also assess whether a clear therapeutic benefit of the proposed intervention can be identified. The case patient's emotional distress was isolated to a single lesion and was negatively impacting her academically and socially; for these reasons excision can be recommended. —Dr Dermatoethicist None disclosed.